tion of these various products is inert, perhaps authoritative writers, the one unsurpassed in it is inactivated or its activity greatly retarded the field of cerebral surgery, the other unsur- by the various menstrua. We see that scale pep- passed in the field of perimetry, cannot fail to sin, 15 grs. to a fl. 5 ss of distilled water, re- carry great weight. duced the albumin to 4^4 grs. (Test Series Quoting from their paper (p. 597) :— No. 5, Tube No. x), and to 33,4 grs. (Test Series "A constriction of the field of vision due to a de- No. Tube No. vti). Scale in the pro- 6, pepsin struction of fibres more of found in the complete from the temporal portion .3% (as gastric juice) than from the nasal half of the retina and justify- did not exert any great effect, the albumin ing the designation of nasal hemianopsia has been 8 or 9 Series No. weighed grs. (Test 5, Tube observed in from 5 to 6% of a series of 500 cases of No. vin. The reader may make other deduc- brain tumor.". . . "It is difficult or impossible to at- tions by studying and comparing the tables. tribute the ultimate binasal blindness to a lesion The first three series demonstrated as far as confined alone to the nerve and retina. Another visible results could be judged, that the higher factor must come into play, which elsewhere in the course of the nerve affects uncrossed fasciculus temperature of 125° F. did not cause any greater the digestive effect than did the temperature of from the temporal retina more markedly than the 100° F. to 104° F. crossed fibres from the nasal retina. We wish to that this be due other tests suggest may to pressure of the di- Many could be performed along lated [third] ventricle, which forces the exposed these for of va- lines, instance, comparison the nerves or tracts adjoining the chiasm downward rious makes of scale pepsin; comparison of the and outward against the resistant carotid vessels, effect of the same preparation on albumin boiled which transversely indent the outer aspect of the for different periods of time, as ten, fifteen, nerves. In this way the uncrossed fasciculi to the twenty or thirty minutes; dried albumin might temporal retinae, and the laterally placed macular be used; indicators other than egg albumin bundle as well, suffer from a mechanical pressure could be employed; rocking water-bath might 'block' in addition to the diffuse anatomical de- be constructed to represent continuous peristal- struction of fibres throughout the nerve in conse- sis. quence of the contraction of the new tissue forma- tion in the long-standing choked disk." A practical inference suggests that when we we will prescribe pepsin probably get better re- The two points to be discussed are these: the sults scale as by ordering pepsin dispensed a occurrence of binasal hemianopsia and its expla- tablet, capsule, or in sealed packages, to be nation. dissolved water freshly in and taken about a half The of the occurrence of binasal hour after meals. If question hydrochloric acid is indi- hemianopsia is a question of definition. It is cated it may be dispensed separately and or- not easy to give a satisfactory brief definition. dered to be taken well diluted. the scale (All The three things to be emphasized are : first, the pepsin solutions were freshly made at the time loss should be limited to corresponding half of the tests.) fields; second, the loss should be symmetrically Undoubtedly pepsin, like other remedies, has distributed in the two the cause suffered from eyes; third, being improperly dispensed and should be a lesion to the visual centres or paths injudiciously used. Pepsin will not lift a fallen at or posterior to the chiasm, for the funda- stomach ; it will not cure the reflex gastric symp- mental anatomical fact at the foundation of the toms due to gall-bladder disease, chronic appen- idea of hemianopsia is the semidecussation of etc. The crux dicitis, of the whole subject de- the nerves. Cases are not uncommon that optic pends upon fascinating subject of diagnosis. where we get fields not unlike in extent and dis- My personal impressions are that pepsin's rôle tribution those classified as true in hemianopsia, therapeutics will be established and enhanced but of wholly different origin, for example, in its exhibition on exact by indications dependent chronic glaucoma and in retinal or choroidal on accurate diagnosis. lesions symmetrically disposed in the two eyes. These should not be classed as cases of true hemianopsia. They might be called pseudo- hemianopsia. That the authors had some such ON SO-CALLED BINASAL HEMIANOPSIA conception of true hemianopsia as above out- lined would appear from a statement which IN BRAIN TUMOR I quote from the first paper in this series2 :—

BY WALTER B. LANCASTER, M.D., BOSTON. "Thus in considering the prevalence of true hemianopsia in a given series of intracranial tu- The third paper by Cushing and Walker1 in mors, one should exclude from the list the subten- torial lesions which are their series on distortions of the visual fields barred from the possibility in of direct implication of the optic tract and radia- cases of brain tumor is devoted to binasal tions." hemianopsia. The authors detail the histories of a dozen eases with many charts of the fields of To be sure, most of the eases described in the vision and reach several conclusions which are present paper are subtentorial but this of sufficient to tumors, importance warrant discussion, is explained when we recall that the more inconsistency so as any hypothesis backed by such the purpose of the paper is to show how such tu-

The Boston Medical and Surgical Journal as published by > The New England Journal of Medicine. Downloaded from nejm.org at UNIV OF PENN LIBRARY on July 3, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. mors can affect the optic pathway indirectly by disk. The field extends nasally 75° from the pressure of the third ventricle. disk and temporally 75° from the disk. If now a In the cases under discussion the matter is concentric contraction progresses with such uni- complicated by the fact that admittedly the formity that exactly 60° is lost from both nasal chief factor in the loss of vision is the secondary and temporal sides, 15° will be left on each side atrophy consecutive to choked disc. The binasal of the disk. This will leave "a small field cen- hemianopsia is not claimed to be the only fac- tering around the blind spot"—precisely what tor. Thus the question is not, are these fields the authors state3 is the typical finding in their typical of binasal hemianopsia, for of course cases. Are we not justified in saying that these they are not. The question is, are they typical fields are quite satisfactorily explained as due to of secondary atrophy complicated by binasal concentric contraction, the result of changes oc- hemianopsia 1 The presence of the atrophy will curring in the papilla? Were there an inter- account for the fields not conforming to the first current binasal hemianopsia grafted onto the and second requirements of the definition, for a fields, as claimed, we should expect to find that very superficial examination is sufficient to show before the temporal fields had contracted 30° or that the losses are not confined to the nasal fields 40° the process in the nasal fields would have ad- and that they are not even symmetrically dis- vanced with decidedly greater rapidity and tributed in the two nasal fields. At this point it would show a decidedly greater loss than the should be observed that the authors disarm criti- temporal. Assuredly, if we -are dealing with bi- cism by remarking:— nasal hemianopsia there must be a loss of sym- metrically disposed patches in the nasal "It somewhat to fields, may appear imaginative desig- over and above what we should to find if nate the field defects which expect accompany these case the loss were due to concentric contrac- reports as examples of for admit- merely hemianopsia, they and so with tedly fail to show the clean-cut vertical meridians tion, merely kept pace the loss found dividing the blind from the seeing retina, which on the temporal side. often (though not invariably) characterize certain In discussing visual fields it is important to stages of the homonymous and bitemporal field de- bear in mind the margin of error due to the fects, as will be indicated in the later papers in this nature of the phenomena we are measuring. series." There is in.most cases no sharp line of demarca- tion where we can say "on one side vision is To answer the question whether the fields are characteristic of binasal present, on the other side vision is absent and hemianopsia compli- whoever makes the test if find cating secondary atrophy we must first consider will, competent, what is the character of uncomplicated it so." One has only to try it on himself to typical appreciate this. Also the character of the re- secondary atrophy. Authorities hitherto are sults obtained different sized test ob- fairly well agreed.* We may quote Wilbrand by using and jects and different intensities of Saenger as having produced the most monu- illumination, as do a considerable mental work on the subject. After out showing they very increase pointing in the area with the frequent absence of visual disturbances for seeing larger and better lighted a surprisingly long time after marked objects, points unmistakably to the fact that changes what we are is a not an ab- are visible with the and men- measuring relative, ophthalmoscope solute quantity. The personal equation of the tioning the slight enlargement of the blind spot, due to of the examiner multiplied by the personal equation of swelling papilla encroaching on the the the adjacent retina, they state that the typical dis- patient equals result. Perhaps Case 10 is as good an example of this as could be. turbance of the visual fields is a concentric con- any In O.S. with a 1 cm. traction from the toward the centre Fig. 21, shows, test object, periphery a field limited to 15° from the disc with some impairment of the visual both each way. acuity, With a 2 cm. same shows a of these progressing as ad- object, eye binasal secondary atrophy more than other in vances, until, if the process is not arrested, total hemianopsia typical any the whole series. The line of damarcation falls ex- blindness ensues. What sort of fields we may on the vertical meridian expect to find as the process advances? actly except near the The macula where it takes in 5° to 10° temporal half of the visual field is than of the nasal larger somewhat as in the nasal to begin with nasal field, typical homonymous hem- (temporal 90°, With a 3 cm. 60°), so that if the contraction is uniform ianopsia. object the nasal field fairly extends in the horizontal meridian to the time will come when all the nasal field will the ex- be lost while the loss of treme normal limit of 60°—no suggestion of na- (60°), an equal amount sal 20 from the temporal side will still leave 30.° hemianopsia. Fig. shows the same case We at an earlier then shall have a small field extending 15° each stage. way from the blind while the spot visual acuity "Fields show binasal will probably have fallen to less than 10-200. hemianopsia. V. O. S. fin- gers; V. O. D. nil." (Authors' The visual centre of the field of vision is the italics.) macula, but the geometrical centre is the optic * There The chart shows in each eye a has been some question as to the large seeing lacing of the color fields importance of inter- area but it will doubtless be found as stated comprising about 14 the normal temporal by Cushing and Walker, that this of the symptom is not characteristic field. This with a vision of nil disease but is a matter of the personal of shows that the examiner. equation the personal equation must be reckoned with!

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIV OF PENN LIBRARY on July 3, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. The true guiding principle was pointed out by toma and dyschromatopsia, as the primary de- Gushing in the discussion of his second paper at fects and the patient's impressions do not defi- the St. Louis meeting. Alluding to the fact that nitely conflict with this view. The other char- fields, especially color fields, vary as taken by acteristic features which make up the picture different examiners he says4 :— are: The abrupt onset, the soreness and pain and sense of pressure in the eye (and orbit?), "The condition varies at different times. . . The the moderate insuffi- field assumes a somewhat different ophthalmoscopic changes configuration cient to account for total blindness but indica- . . . but it shows this tendency and it shows that one must generalize rather than particularize about tive of some inflammatory process, the termina- these conditions. Possibly, endeavoring to make tion in total amaurosis in one eye (not rare in the matter register, we may have gone a little fur- retrobulbar neuritis, but extraordinary if due, ther than we were justified in doing." as surmised by the authors, to pressure of scle- rosed carotids, but of abrupt onset and with Adopting this valuable suggestion, we must the other eye unaffected for two years) and not be influenced so much by the findings shown lastly the rapid recovery of some vision, but on a single chart, but must weigh the evidence with permanent central scotoma, in the other presented by a series. That is, we must gener- eye, also typical of retrobulbar neuritis. The alize, try to detect the tendency shown by these authors admit that "Without post-mortem ex- fields. Is it a tendency toward binasal hemian- amination one cannot definitely ascribe such a opsia? Or is it simply a tendency toward con- condition as was encountered in this patient centric contraction? How shall we answer this to the lateral pressure of sclerosed vessels." without being influenced by our personal lean- They think it the most likely presumption. They ings toward one side or the other ? Would not a do not discuss the possibility of retrobulbar neu- composite field made up by combining all those ritis. Their explanation of the "unexpectedly charts shown in the paper be likely to show the happy result" of the operation is ingenious but type? I have done this for the horizontal me- not convincing. At all events the fields, espe- ridian. The result was to show an average loss cially the final field, are more typical of retro- in the whole 44 charts of 50.29° nasally and bulbar neuritis than of bi-nasal hemianopsia. 50.23° temporally. This is a sufficiently striking We pass now from the question of the occur- confirmation of the suggestion that the real ten- rence of binasal hemianopsia to the second ques- dency here shown is toward a concentric con- tion raised by the paper we are discussing—the traction affecting both sides about equally. explanation. Two are suggested. explanations ' In addition to constructing the composite field Of these two the authors say they ' are at pres- I have gone over each case separately and fail to ent inclined to lay chief stress on the influence find any distortion of the fields which cannot of the bilateral arterial constriction," meaning be explained readily as due to secondary the pressure of the carotids on the optic nerves. atrophy. It is not to be supposed that each case We have already discussed this above. Were will show symmetrical uniform contraction. By there such a factor operative it would, as we no means. That is the "tendency," but indi- have said, inevitably produce greater loss in the vidual cases will vary somewhat irregularly from nasal fields than we should expect to find were this type. One of the charts of the left eye of concentric contraction alone operative and judg- Case 1 (Fig. 2) shows 20° more loss from the ing progress by the stage reached in the tempo- nasal than from the temporal side. This does ral fields. It appears that this does not occur. not at first look like concentric contraction. There is no apparent tendency for contraction When we investigate it we find that V. equals of the nasal periphery to advance faster or far- fingers at 4 inches. In an eye so nearly blind ther than the temporal.* we cannot attach great weight to the exact limi- But, even if the objections which I have raised tations of the fields. The same criticism applies were not valid, the authors evidently do not to Case 8, "acuity practically nil"; and to Case feel that the theory is entirely satisfactory on 9, "acuity not measurable." I have already other grounds. There is little anatomical and mentioned some weak points about Case 10. The microscopic support for it. It is apparent that last case reported (not under the head of brain it was put forward by the authors as the best tumor) appears to have been a fairly typical hitherto suggested (it was first suggested by case of retrobulbar neuritis. It is described H. so "are for the in- ' ' by Knapp) ,and they present the authors as, Blindness with primary involve- clined to adopt it. ' ' Although the chiasm toler- ment of nasal vision in each eye, presumably ates considerable slow pressure, it is hard to be- from pressure of sclerotic vessels." Examina- lieve that there can be sufficient pressure upon tion of their records show that the loss of vision it from the third ventricle to force the nerves was with little doubt primarily a central scotoma against the carotids (not always sclerosed, one pa- with dyschromatopsia. No fields were taken at tient was under 10 yrs.) strongly enough to de- this stage, therefore we have to rely on the pa- stroy the nerve fibres without the direct pressure tient's impressions and on the course of recov- which tends to * A lesion affecting the outer aspect of the chiasm (as distin- ery, reverse the course of onset guished from the optic nerve near the chiasm) cannot cause nasal and is an indication of value. This hemianopsia because at this point the uncrossed fibres to the great points temporal retina (nasal field) are inextricably interwoven with the very definitely and unmistakably to central sco- crossed fibres to the other half field.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIV OF PENN LIBRARY on July 3, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. of the ventricle damaging the part of the chiasm are the most vascular and contain the most nerve on which it impinges, the more so as not all of fibres. Here the edema first appears, reaches its the pressure exerted by the ventricle is trans- greatest intensity, lingers longest. The central, mitted to the two arteries; most of it must be nasal and most superficial fibres are the ones taken up by the other structures which resist most exposed to the swelling, the round-cell in- the displacement, especially by the chiasm itself, filtration, the formation of connective tissue, the before any can reach the arteries. Indeed, it cicatrical contraction, and the secondary at- has been suggested frequently ( Oppenheim, Wil- rophy. The deeper lying fibres all around and brand and Saenger and others) that the pressure the fibres on the temporal side of the disk would of the third ventricle might cause bitemporal seem to be the least exposed, especially the deep- hemianopsia or total amaurosis, but never before lying fibres at the periphery of the disk. that it might cause binasal hemianopsia. The authors raise the question whether the The second explanation suggested, but not fa- fibres which come from the area of the retina vored by Cushing and Walker, is that the cause adjacent to the disk, which are the last to suf- ' ' is located in the papilla. Can it be shown that fer, enter the nerve head in some specially pro- the processes in the papilla are adequate to ex- tected—possibly central—position." Also they plain the facts? Evidently the authors would give a diagram showing the central fibres which be glad to accept this explanation did they not they surmise are the ones preserved. Is it not think the objections insuperable. evident that the central and superficial fibres are the ones that are least protected and first to some anatomical condition ac- "Unquestionably be damaged. Possibly the authors were led counts for the fact that with an choked advancing some confusion as to the distribution which has at which astray by disk reached the stage recession in the of fibres of the to cicatrical papilla the from the retina. swelling occurs, owing contrac- did the new-tissue forma- tion, the fibres which are last destroyed are those They say:7 "Moreover, originating from the nasal retina in the vicinity of tion at the papilla shut down in centripetal the optic papilla."5 fashion on the nerve head and implicate the fibres from the periphery inward, we would ex- The changes in the appearance of the optic pect an early involvement of the macular bundle papilla are so striking and the changes found with a central scotoma as a common instead of a elsewhere so slight, that one naturally looks there rare early feature." That is, by what was per- for the explanation of the loss of function. It haps a slip of the pen, they make the fibres from is to be noted that the simple edema, which is the area adjacent to the disk occupy the center the first stage of a process which ends, if not and superficial part of the papilla and the fibres arrested, in total atrophy, can reach a very high from the periphery of the retina occupy the degree, and last a considerable time without marginal region of the papilla. It is the causing noticeable loss of vision. When the deepest, the marginal fibres of the papilla, swelling begins to subside and evidences of which come from the retina close to the disk, atrophy appear, vision is markedly affected. the more superficial and central ones passing Whether the swelling diminishes because at- over these as they come from the periphery of rophy has set in (Behr) or whether atrophy the retina. sets in because shrinking of the papilla An additional factor in causing peripheral has begun, is disputed. The facts are contraction of the fields, especially in the stages tha.t as atrophy appears the fields show more before atrophy has set in, is to be found in the contraction and acuity falls. This means that retinal ischaemia due to pressure on the arteries the fibres which come from the periphery in par- by the choked disk. Naturally the periphery of ticular and the fibres from other parts of the the retina is most affected and especially the field in less degree are damaged. The results temporal retina (nasal field) because most re- shown by taking fields with small and with large mote from the source of blood supply. test objects indicate that the damage even to the Lastly, Behr, who took this as the starting peripheral fibres is not at first total. Some fibres point in constructing his theory of the patho- are preserved at least sufficiently to conduct genesis of choked disc, explains the peripheral such sensations as large test objects excite. contraction of the fields by attributing it to Gradually more fibres are affected and to a pressure on the nerves in their intracranicular greater degree. The result is a progressive con- portion. Perhaps it will be found that this is an traction of the field and a fall in acuity. The important factor. cause at work then would to be one which appear summary. affects the nerve fibres to some extent through- out the retina, but chiefly those coming from the 1. It is better to adhere to the classical con- periphery. ception of hemianopsia and require for admis- Is not this just what might be expected of the sion to that category that the cases must show processes known to be taking place in the symmetrical losses limited (unless a complication papilla ? The swelling starts as a damming back is present) to a half field of each eye and due to of the natural outflow of lymph through the a single lesion affecting the visual centres or centre of the optic disk (physiological pit) along pathways at or posterior to the semi-deeussation the blood vessels.6 The centre and the nasal half of the optic nerves. Fields which simulate these,

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIV OF PENN LIBRARY on July 3, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. but are of totally different origin (glaucoma, at- nostic results. In such lateral projections, when rophy, retinitis) may be called pseudo-hemian- made veritably so, the structures placed bilat- optic. erally to the right and the left of the median 2. The cases reported by Cushing and line become, as to "shadow," superimposed. It Walker, as examples of binasal hemianopsia, has been rightly asserted that such superimposi- when all the charts are combined into one com- tion of projection is fatal to differential diag- posite chart to determine the type, show that the nosis as between right and left ; especially is this true type of loss of the visual fields is a concen- true of the maxillary sinus and of the frontal tric contraction affecting both half fields equally sinus, not to speak of their immediate neighbors, and therefore not to be called hemianoptic ac- the anterior ethmoidal colonies of cells. Fur- cording to the accepted use of the term by oph- ther, it has been asserted that a projection, by thalmologists. x-rays, of the lateral aspect of the skull is of 3. The characteristic form of the visual fields little value save to determine the depth of the in secondary atrophy is probably due to the dis- frontal sinus. Thus in the lateral aspect of the tribution of the fibres in the nerve head. This skull, in so far as Roentgen examinations are distribution is such that the superficially located concerned, the familiarity nurtured in an easy fibres are most exposed to the pathological proc- technic has come to breed a contempt for the esses and are the first to succumb while the deep- character of the information this projection has est and most peripheral fibres of the papilla are to offer. It is the writer's feeling that nearly the last to suffer. These come from the area of all—and among them many Roentgenologists— the retina adjacent to the optic disk, thus ac- who habitually see Roentgen projections of the counting for the tendency noted by Cushing and lateral skull, fail to appreciate how much is af- Walker "for the fields to become limited to a forded for inspection, especially in the vicinity small bitemporal field surrounding each blind of Reid 's base-line. spot." So complex is the collective Roentgen por- 4. Were this process complicated in some trayal of the structures in the immediate vicinity cases, as suggested by Cushing and Walker, by of the cranial-base that simple inspection, at first a pair of symmetrical lesions affecting the outer glance, usually does not mean observation in its aspects of the optic nerves near the chiasm fullest sense. Study alone can ensure a produc- where the uncrossed fibres which come from the tive interpretation. temporal retina are superficially situated, the For limitary purposes in a consideration so damage to these fibres should show itself in a brief, we must assume that the adnexa of the modification of the form of the visual fields. skull-base are bounded anteriorly by the infra- The loss from the nasal fields should exceed what orbital ridge and posteriorly by the median we should expect to find, judging by the prog- occiput. Thus limited, a lateral in Roentgen ress of the loss the temporal fields. This does projection of these adnexa presents for con- not seem to occur. sideration five principal entitative regions: (1) 5. The last case in their series is probably an the orbital, (2) the frontal, (3) the posterior example of retro-bulbar neuritis. ethmoidal, (4) the sphenoidal, and (5) the hypo- physeal. the REFERENCES. Strictly speaking, mastoid region 1 falls without the above Arch. Oph., vol. xli, No. 6, 1912 arbitrary limitation, al- 2 Bull. Johns Hopkins, 1911, p. 194. though the lateral aspect of the 3 Pp. 572, 597 et al. skull, by x-rays 4 with technical Jour. Am. Med. Asso., 1911, vol. lvii, p. 220. applied accuracy, furnishes here a 6 P. 595. 6 amount of information Behr, Wilbrand and Salnvn prodigious (Lange15, ie). 7 P. 597. The orbital region, when projected laterally, suffers by superimposition of its right and left aspects, as do all structures bilaterally placed. The orbit becomes a source of radiographie in- formation chiefly when its territory is invaded THE DIAGNOSTIC EVIDENCE OBTAINED from without, either by foreign substances BY X-RAYS FROM THE LATERAL AS- {e.g. flying metallic fragments), or by neoplastic PECT OF THE SKULL, WITH ESPECIAL masses from behind and above {e.g. endothelio- REFERENCE TO THE BASE AND ITS mata). In the first instance, the normal contour ADNEXA of the orbital cavern is disturbed not at all, save where the projected foreign body has shattered it BY PERCY BROWN, M.D., BOSTON. or is impacted within it. Invasion from above or behind, however, by adjacent morbid After the classical contribution of pro- Caldwell5 cesses, may produce a partial or complete oblit- the of the upon skiagraphy accessory nasal si- eration of its usual Roentgen appearance or an nuses, in which he emphasizes the absolute neces- effacement of the usual recognizable periorbital sity of the occipitofrontal projection of the cra- partitions and barriers. nium as the key to Roentgenologic problems in Changes in the mural dimensions and in the this region, the lateral projection, with its sim- intramural hiatus normally presented the sank into at by pler technic, desuetude, or least into frontal region (frontal sinuses) are to be ob- as a sine non to served secondary importance, qua diag- in lateral projections of the skull and may

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIV OF PENN LIBRARY on July 3, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society.